Shared Governance Empowers Nurses at Nemours Hospital for Children

Added on Jun 22, 2017

Shared Governance Empowers Nurses at Nemours/Alfred I. duPont Hospital for Children
By Diana Mahoney
Industry Edge June 2017

At Nemours/Alfred I. ​duPont Hospital for Children, nursing shared governance isn’t a “nice to have,” it’s a “must have.”

Defined as a decision-making model in which nurses are organized to make decisions about clinical practice standards, quality improvement, staff and professional development, and research, nursing shared governance is recognized as an essential component of an effective practice model, and it is foundational to the Wilmington, Delaware-based organization’s status as a Magnet hospital, according to Jane Mericle, Nemours’ chief nurse executive.

“One of the prerequisites for Magnet designation is having a system in place that supports shared leadership and participative decision making, and promotes nursing autonomy,” Mericle said. In addition, she said, nursing shared governance is the vehicle through which Nemours nurses are able to consistently deliver on the promise of compassionate and excellent patient care. “When nurses are empowered to make decisions, the quality and safety of care improve.”

By encouraging accountability and ownership of patient care outcomes, shared governance enables joint problem solving between ​our teams and leadership, giving everyone a voice in the way patients are cared for, explained Mericle. “Involving the people who are closest to the patients in decisions that affect patient care makes much more sense than making decisions independent of their input. It also provides a framework for how nurses are treated by nurturing a culture built on mutual respect,” she said. Such a culture drives engagement, increases nurse satisfaction and reduces turnover—three considerations that exert a strong influence on patients’ perceptions of the care they receive.

Evidence of the success of Nemours’ nursing shared governance model can be seen in organizational performance on nursing-sensitive patient experience measures, which typically average between the 93rd and 99th percentiles, and in the system’s performance on NDNQI® RN Survey with Job Satisfaction Scale-R (JSSR) items, such as nurse autonomy, decision making, nursing administration, nursing management and RN-to-RN communication, in which the hospital ranks above the national mean.

These outcomes go hand in hand, noted Norine Watson, the hospital’s director of nursing excellence. “We couldn’t have achieved such consistency around patient experience scores without nurses who are engaged in and satisfied with the environment in which they work and the way decisions are being made,” she said. “The bottom line is that, when you have an engaged nurse who feels valued, that translates directly to the quality and experience of care they provide.”

Developing a Shared Governance Model That Fits

When it comes to nursing shared governance, there are two indisputable facts: There is no one-size-fits-all solution, and naming a governing structure “shared” does not make it so.

“There is no one right structure for shared governance,” stated Watson. Each organization must design a model that fits with its organizational culture, resources and goals, she said.

Ideally, the deliberative units should be small enough to support effective decision making, but large enough to ensure sufficient representation. At Nemours, this means having an overarching structure to guide system-level decisions as well as sublevel governing bodies based on area of influence, Watson explained.

Central to the Nemours shared governance model is its Nursing Shared Governance Congress (SGC), which includes two elected nurse representatives from each clinical area and focuses on ways to standardize nursing practice globally across the institution. In addition to the congress, seven Nursing Shared Governance Councils, which are facilitated by a Nursing Executive Council, have been established to address concerns relating to their unique nursing practice. The seven councils include
  • Nursing Informatics Council
  • Nurse Management Council
  • Nursing Practice Council
  • Nursing Quality Council
  • Nursing Research Council
  • Nursing Education Council
  • Advanced Practice Registered Nurse Council
By design, each council has a different sphere of influence. For example, the Nursing Quality Council focuses on performance across nursing-sensitive quality indicators—evaluating current performance, identifying areas in need of improvement and brainstorming ways to improve. An early example was the council’s evaluation of patient care in the pediatric intensive care unit (PICU) and its determination that the setup for certain kinds of equipment directly influenced infection rates. Consequently, the council assigned a multidisciplinary team to draft new setup procedures which led to improved infection rates.

Similar consensus-based decisions have led to process and practice changes in each council area. The breadth of the representation the model allows ensures that nurses at all levels of the organization share ownership in the successes, Watson said. “In any given month, we have more than 200 nurses and nurse leaders engaged in shared governance as part of these council meetings, and the decisions they are making become part of the larger dialogue in the congress that relate to the strategic direction of the organization,” she explained. “This is very important to us, and to the success of our shared governance approach.”

Because structure alone cannot guarantee true shared governance, the SGC regularly surveys the nursing staff using the validated Index of Professional Nursing Governance (IPNG) questionnaire “to make sure that what we are calling shared governance is actually perceived to be so,” Watson said.

The IPNG tool measures nurses’ perception of overall nursing governance, in addition to six subscales of professional nursing governance (personnel, information, resources, participation, practice and goals) along a continuum from traditional, to shared, to self-governance. Higher scores on the measure reflect nurses’ belief that they have influence over their practice and governance decisions.

Based on the results of the most recent IPNG survey of Nemours nurses, which were shared during a Nursing Grand Rounds presentation in early spring, “our scores were good! They fell inside the range for shared governance vs. self-governance or authoritarian,” Watson explained. “This confirms that we are on the right track and moving in the right direction.”

It does not mean there are no disconnects, however. “Our objective is to place decisions about practice and quality in the hands of the people that have control over practice and quality, but inevitably, issues will bubble up where nurses might feel as if they are not being heard,” Watson said. This can happen if the local structure of shared governance at the unit level “isn’t as strong as we’d like it to be,” she noted. For example, if a unit representative serving on one of the councils is not engaging in open dialogue with the nurses on the unit, the “voice” of the unit may not be well-represented.

One way the SGC plans to identify and address these pockets of vulnerability is to ​assess nurse perceptions of shared governance at the unit level. “Understanding the perception and impact of shared governance at this level will give us important insight into how nurses in individual practice areas understand the role and function of shared governance and how we can best support them,” Mericle said. Given the link between engagement in shared governance and positive patient outcomes, such insight has important clinical implications for inpatient and outpatient areas, she added, “and will further empower our staff nurses to be more engaged in processes that impact their practices.”